Clinical Handbook of Mindfulness (59 page)

particular phrases or sentences utilized during the mindfulness groups

(e.g., “thoughts are mental events, not facts,” “thoughts and emotions

are transient and impermanent events”) or to invite the patient to use

specific metaphors related to mindfulness (e.g., “thoughts like clouds in

the sky”; see also Chapter 7 of this volume). The aim in this phase is not

to change the content of the thoughts, but to change the way in which

the patient relates to them.

(E) For the duration of the entire session, it is particularly important to

invite and help the patient to prevent any overt or covert neutralization

through rituals or compulsions by asking him/her on a regular basis what

he/she is thinking he/she will do in that moment or after the session (rit-

uals) or if he/she is using any neutralizing thoughts in order to deal with

anxiety and distress. If so, the patient is invited to let go of the neutral-

ization and to bring his/her attention back to the real physical sensations

or sensory experience in the present moment, rating how the level of

distress changes (on a scale 0–100) moment by moment. The patient is

also invited to notice how discomfort is expressed by specific physical

sensations and be aware of where they are located in the body.

(F) The session should end with a short mindfulness exercise (e.g., Breath-

ing space –
Segal et al., 2002)
aimed at allowing the patient to recover a sense of balance, stability, and presence.

Outcome Research

At present there are no randomized and controlled trials that have investi-

gated the effectiveness of a mindfulness-based treatment with OCD. How-

ever, there are some studies that have suggested a positive and significant

outcome using various adapted forms of Mindfulness-based approaches or

meditation with this disorder.

Chapter 11 Mindfulness and Obsessive-Compulsive Disorder

211

In a clinical case study,
Singh, Wahler and Winton (2004)
present the case of a patient who learned improved her quality of life by reframing her OCD as

a strength and enhancing her mindfulness so that she was able to incorporate

her OCD in her daily life. Results showed that she successfully overcame

her debilitating OCD and was taken off all medication within 6 months of

intervention. Three year of follow-up showed that she was well adjusted and

had a full and healthy lifestyle and that although some obsessive thoughts

remained, they did not control her behavior.

In another case report,
Patel, Carmody, and Blair Simpson (2007)
present an OCD patient who refused treatment with medication or EX/RP and was

treated using an adapted Mindfulness-Based Stress Reduction (MBSR) pro-

gram. After an 8-week adapted MBSR program, the endpoint evaluation

revealed clinically significant reductions in symptoms of OCD as well as an

increased capacity to evoke a state of mindfulness.

Schwartz, Stoessel, Baxter, Martin & Phelps
(1996)
investigated the effects of a cognitive-behavioral intervention integrated with mindfulness-based

components (the Four Step Program) for a group of OCD patients. This

study, which used brain-imaging methods (PET), showed that mindfulness-

based treatments were associated with significant structural and functional

change in the cerebral dysfunctions in the areas connected to the disorder

(
self-directed neuroplasticity
;
Schwartz & Beyette, 1997; Schwartz & Begley,

2002; Schwartz, Gullifor, Stier, & Thienemann, 2005a).
Some neuroimaging research shows that patients with OCD would be capable of “reconstructing” the neuronal circuits associated with the disorder
(Schwartz & Beyette,

1997; Schwartz, 1998)
when mindfulness-based methods are adopted. Con-

sciously directed attention may cause a cerebral re-organization, which leads

to more adaptive cerebral and behavioral functioning (the
quantum zeno

effect
)
(Graybiel, 1998; Graybiel & Rauch, 2000;
Beauregard, Levesque & Bourgouin,
2001;
Ochsner, Bunge, Gross, & Gabrielli, 2002; Paquette et al.,

2003;
Schwartz, 1999).
More specifically, these authors hypothesized that repeated acts of mindfulness, regularly practiced, could lay down circuitry

in the habit-forming part of the brain in the
basal ganglia
(Graybiel, 1998).

Prefrontal cortex mechanisms
would be directly influenced in highly adap-

tive ways by wilfully instituting the mindful cognitive reframing perspec-

tive
(Beauregard et al., 2001;
Ochsner et al., 2002; Paquette et al., 2003).

Regular practice of mindfulness would rewire the brain in ways that tend

to calm the pathologically overactive orbital-frontal cortex, anterior cingu-

late gyrus, and caudate nucleus circuitry through
self-directed neuroplastic-

ity
(Schwartz, 1999).
These studies also show that brain metabolism in the orbital-frontal cortex changes in a significant manner when OCD patients

apply mindfulness-based approaches
(Schwartz & Begley, 2002).

Furthermore, in a recent pilot study (Didonna & Bosio, work in progress)

the authors investigated the effect of an adapted form of MBCT for a group

of six OCD patients (Y-BOCS mean total score 21). Preliminary data on this

open trial showed that 4 out of 6 patients had a significant improvement

in the Y-BOCS and Padua Inventory scores at the end of treatment and that

they maintained this outcome at a 6-month follow-up (three of them were

fully remitted). From the beginning of the MBCT group until the follow-up,

the patients didn’t receive any other kind of psychological treatment and

those who were on medication had no changes in their dose from 4 months

before MBCT GROUP until the follow-up. The 4 patients who made improve-

212

Fabrizio Didonna

ments maintained a medium-high level of mindfulness practice during the

group and after 6 months. An interesting correlation between a significant

improvement in OCD symptoms (post treatment and follow-up) and a sig-

nificant improvement in Mindfulness skills at post treatment and follow-up

(assessed using FFMQ, see Baer et al., Chapter 9 of this volume) was also

observed .

These findings are encouraging, but further investigation using controlled

and randomized trials with large samples is needed to confirm the effects and

mechanisms illustrated above, and to understand to what degree mindfulness

components affect and improve therapy outcomes.

Conclusions and Future Directions

The true voyage of discovery is not in seeking new landscapes but in having

new eyes.

– Marcel Proust.

The introduction of mindfulness-based interventions into the psycholog-

ical treatment of OCD is a relatively recent application even though the

progress that these approaches have attained in the last two decades is note-

worthy. From a mindfulness-based perspective, OCD can be conceptualized

as a deficit in mindfulness skills. A Mindfulness-based approach seems to be

a promising intervention that may improve some of fundamental mindful-

ness skills that are involved in the phenomenology of obsessive patients.

More specifically, Mindfulness practice may strengthen exposure experi-

ences and, since it is an antiavoidant strategy and an antirumination process,

improve the attentional deficit in OCD. Furthermore, it has been hypoth-

esized that Mindfulness may teach patients to validate private experience

and prevent the secondary elaborative processing that is one of the main

activating factors in the obsessive syndrome. Self-validation and acceptance

are proposed as therapeutic attitudes that can modify the constant ongo-

ing obsessive self-invalidation of one’s own private experience and memory

of it. The perception experience validation technique (PEV), described in

this chapter, is a mindfulness procedure that may help patients with obses-

sive problems enhance their ability to acquire mindful attention and use the

memory of their own sensorial experience in order to deal with doubt and

rumination.

Mindfulness can help patients realize the
impermanence
of experience

(using acceptance, allowing, “letting be” attitudes, and metaphors), develop-

ing a sense of
not-self
and
non-attachment
(using detachment, disidentifica-

tion and defusion processes), with no need to control or react to thoughts.

Mindfulness training may also be a valuable intervention for improving

metacognitive skills and increase patients’ insight, reality testing, and general

functioning. It may also help patients learn to avoid activating the maintain-

ing factors of OCD that lead to the chronic and self-reinforcing vicious cycles

of the disorder (see Figure 11.3).

Mindfulness is a less specific intervention than standard behavioral tech-

niques because it is aimed at teaching patients a different attitude, mental

style, and way of being present to their entire private experience. This may

have positive implications with respect to the intervention with OCD since

it is such a heterogeneous nosographic entity with numerous comorbidities.

Chapter 11 Mindfulness and Obsessive-Compulsive Disorder

213

These patients, in fact, might need a therapeutic integration with a more

comprehensive approach to their dysfunctional way of relating to thoughts,

emotions and sensations, integrating in this way mindfulness for OCD into a

complete view of the emotional suffering and disease of these patients.

Mindfulness practice can feasibly be integrated into traditional interven-

tions for OCD. Such data as are currently available, as well as clinical obser-

vation, suggest that the effectiveness of established treatment programs

for obsessive problems may be increased by adding mindfulness training

or mindfulness-based components. In some cases, integration is associated

with an improvement in therapy outcome in individuals who were previ-

ously described as refractory or resistant to traditional interventions. Further-

more, mindfulness offers an effective and less frightening integration with

CBT, and in particular ERP, reducing the risk of drop-out, which is high for

OCD patients who start a cognitive-behavioral intervention based on expo-

sure techniques. Mindfulness may enhance motivation to use these anxiety-

inducing, but effective, strategies.

A question for further exploration is whether or not there are any con-

traindications for mindfulness-based treatments of some kinds of severe OCD

patients. Clinical experience and observation at my Unit for Mood and Anx-

iety Disorder suggests that, in general, there are no particularly significant

contraindications for these approaches, or for integrating them into already

existing protocols – even for challenging problems and with different types

of obsessive domains. Moreover, the author has noticed that this kind of treat-

ment may be more effective with obsessive checkers and cleaners, and that

there could be a poorer response with people with poor insight and lower

egodistony (e.g., individual with overvalued ideation). In any case, methods,

strategies, and forms of meditation (mindfulness practice) that are specifi-

cally tailored for the heterogeneity of OCD and for comorbid disorders such

as depression, personality disorder, and dissociation, need to be found. For

example, perhaps patients with severe symptoms should be prepared grad-

ually for the practice of mindfulness, and interventions should be integrated

with CBT. With severe problems it is very helpful to provide mindfulness

training in which patients can shift
gradually
from external sensory aware-

ness (e.g., walking meditation) to inner mindfulness experiences (e.g., body

scan), from short to long exercises, and from informal mindfulness practice

to formal meditation (see also Chapter 24).

At present too few studies have investigated the therapeutic ingredients of

Mindfulness for OCD to draw firm conclusions about the precise mechanisms

of change. However, a number of tentative observations can be made. From

the available data and clinical observation it seems that mindfulness-based

interventions may lead to changes in some specific
mindfulness deficits
such

as attentional biases, rumination, thought-action fusion, inflated responsibil-

ity, and self-invalidation of private experience. A central issue that requires

further investigation is whether or not there are particular brain processes

associated with the clinical conditions of OCD that mindfulness practice

either alters
(Farb et al., 2007;
Schwartz et al., 1996;
Lazar et al., 2005).
There is a need to understand the cognitive, emotional, behavioral, biochemical,

and neurological factors that contribute to the state of mindfulness (See also

Chapter 3 of this volume), and to investigate the mechanisms through which

mindfulness training may create clinical change in OCD.

214

Fabrizio Didonna